Hydrocephalus related to pulsion diverticulum of lateral ventricle

Congenital aqueduct stenosis: Progressive brain findings in utero to birth in the presence of severe hydrocephalus

PURPOSE

To evaluate the effects of progressive hydrocephalus on the developing brain in a cohort of fetuses diagnosed with congenital aqueduct stenosis by comparing prenatal magnetic resonance imaging and postnatal imaging.

METHODS

This IRB approved single center retrospective review of prenatally diagnosed children with congenital aqueduct stenosis interrogated changes in the brain between prenatal and postnatal imaging and analyzed statistics using SAS software package version 9.3.

RESULTS

Thirty fetuses imaged at a mean gestational age of 26 weeks had aqueduct obstruction confirmed by postnatal imaging. Progressive hydrocephalus required shunting in all but one patient (97%). Those patients with increasing hydrocephalus showed increase in ventricular rupture (60%), loss of septal leaflets (47%), and reduction in white matter and corpus callosum volume (43%). Cerebellar ectopia developed in 27% with 6% meeting the criteria for Chiari I malformation.

CONCLUSION

Hydrocephalus in the fetus results in enlarging ventricular rupture, loss of the septum pellucidum leaflets, volume reduction of brain parenchyma including corpus callosum, and risk for Chiari I anomaly. Given advances in fetal surgery and imaging in the last 3 decades, there may be cause to revisit the idea of in utero cerebral spinal fluid diversion as a means to potentially ameliorate progressive loss of the developing brain.

[Lateral ventricle diverticulum as a variant of hydrocephalus evolution]

A clinical case of a 12 year-old girl with hydrocephalus complicated by rare condition, lateral ventricular diverticulum, is reported. Progression of the diverticulum was followed up according to MRI. The diverticulum of the lateral ventricular wall has emerged in the interval of 1 year (14 months have passed between the two MRI examinations) and spread towards the quadrigeminal cistern. In addition, compression of cerebellum, aqueductus cerebri Sylvii, and the fourth ventricle of the brain have emerged. A surgical treatment was suggested after the hydrocephalus had been initially revealed (when the diverticulum had not been formed yet); however, the child's parents refused the therapy. One year later, a series of epileptic seizures emerged, and MR scans showed a cystic neoplasm in the postcranial fossa above the cerebellum. The genesis of the cyst and its nature were unclear and additional invasive examination methods were required. MSCT ventriculography confirmed the diverticulum of the right lateral ventricle towards the quadrigeminal cistern.

Hydrocephalus in aqueductal stenosis

INTRODUCTION

The sylvian aqueduct is the most common site of intraventricular blockage of the cerebro-spinal fluid. Clinical aspects, neuroradiological appearance, and treatment of hydrocephalus secondary to aqueductal stenosis are specific.

METHODS

An extensive literature review concerning etiologic, pathogenetic, clinical, and neuroradiological aspects has been performed. Therapeutic options, prognosis, and intellectual outcome are also reviewed.

CONCLUSION

The correct interpretation of the modern neuroradiologic techniques may help in selecting adequate treatment between the two main options (third ventriculostomy or shunting). In the last decades, endoscopic third ventriculostomy has become the first-line treatment of aqueductal stenosis; however, some issues, such as the cause of failures in well selected patients, long-term outcome in infant treated with ETV, and effect of persistent ventriculomegaly on neuropsychological developmental, remain unanswered.

Endoscopic observation of pathophysiology of ventricular diverticulum

BACKGROUND

Although there have been reports dealing with ventricular diverticulum (VD) analyzed by cisternography and computed tomography (CT), those focusing on magnetic resonance imaging (MRI) or neuroendoscopic findings are rare.

CASE REPORT

We present a case of noncommunicating hydrocephalus caused by aqueductal stenosis with cystic lesion located in supracerebellar region. Third ventriculostomy was performed on this case. The conventional CT and MRI were compatible with usual VD, but neuroendoscopic examination suggested otherwise. The endoscopic view inside of the cystic lesion demonstrated passing veins and no membrane. We diagnosed this cystic lesion as a unique subtype of advanced VD mimicking spontaneous ventriculostomy. Endoscopic observation of the cyst was very useful for accurate diagnosis and safe treatment.

Lateral ventricular diverticulum extending into supracerebellar cistern from unilateral obstruction of the foramen of monro in a neonate

A ventricular diverticulum is usually found in patients with long-standing severe obstructive hydrocephalus that may extend into the supracerebellar cistern. The route involved in the supracerebellar extension of the ventricular diverticulum is believed to originate through the tela choroidea of the temporal choroid plexus or of the antral choroid plexus. The authors report a 4-week-old girl with hydrocephalus as a result of unilateral obstruction of the foramen of Monro, which dilated the right ventricle and displaced the midline to the left side, collapsing the contralateral lateral ventricle. The dilated lateral ventricular diverticulum herniated to the supracerebellar cistern in the posterior fossa that compressed the cerebellum inferiorly. She was treated successfully by a ventriculoperitoneal shunt, resulting in a marked reduction of the ventricle and diverticulum on the follow-up computed tomography and magnetic resonance imaging. We reviewed the literature for the supracerebellar extension route of ventricular diverticulum and suggest that the medial choroidal fissure in the antrum and the velum interpositum may be important anatomical structures for the extension of the lateral ventricular diverticulum into the supracerebellar cistern.

Pathogenesis and diagnostic pitfalls of ventricular diverticula: case report and review of the literature

OBJECTIVE AND IMPORTANCE

Ventricular diverticula are local herniations of the ventricular system occurring in association with severe, long-standing hydrocephalus. Variability in the extent and location of these ventricular pouches may produce misleading radiological conformations and raise diagnostic challenges. In this report, we discuss the pathogenesis and differential diagnosis of ventricular diverticula on the basis of a case illustration.

CLINICAL PRESENTATION

We report the case of a 38-year-old woman presenting with hydrocephalus secondary to an obstructive lesion of the third ventricle. A large, dilated structure compressing the brainstem was present in the posterior fossa.

INTERVENTION

The posterior fossa lesion was identified as an atrial diverticulum by injection of contrast medium into the right lateral ventricle, which led to immediate enhancement of the infratentorial cavity. Ventricular drainage and removal of the third ventricular lesion, a colloid cyst, allowed progressive collapse of the diverticulum and symptom resolution.

CONCLUSION

This report discusses the pathogenesis of ventricular diverticula and demonstrates that ventriculography can be used to differentiate atrial diverticula from other posterior fossa lesions when time-consuming multiplanar magnetic resonance imaging cannot be afforded on an emergency basis.

Sylvian aqueduct syndrome and global rostral midbrain dysfunction associated with shunt malfunction

OBJECT

This study is a retrospective analysis of clinical data obtained in 28 patients affected by obstructive hydrocephalus who presented with signs of midbrain dysfunction during episodes of shunt malfunction.

METHODS

All patients presented with an upward gaze palsy, sometimes associated with other signs of oculomotor dysfunction. In seven cases the ocular signs remained isolated and resolved rapidly after shunt revision. In 21 cases the ocular signs were variably associated with other clinical manifestations such as pyramidal and extrapyramidal deficits, memory disturbances, mutism, or alterations in consciousness. Resolution of these symptoms after shunt revision was usually slow. In four cases a transient paradoxical aggravation was observed at the time of shunt revision. In 11 cases ventriculocistemostomy allowed resolution of the symptoms and withdrawal of the shunt. Simultaneous supratentorial and infratentorial intracranial pressure recordings performed in seven of the patients showed a pressure gradient between the supratentorial and infratentorial compartments, with a higher supratentorial pressure before shunt revision. Inversion of this pressure gradient was observed after shunt revision and resolution of the gradient was observed in one case after third ventriculostomy. In six recent cases, a focal midbrain hyperintensity was evidenced on T2-weighted magnetic resonance imaging sequences at the time of shunt malfunction. This rapidly resolved after the patient underwent third ventriculostomy.

CONCLUSIONS

It is probable that in obstructive hydrocephalus, at the time of shunt malfunction, the development of a transtentorial pressure gradient could initially induce a functional impairment of the upper midbrain, inducing upward gaze palsy. The persistence of the gradient could lead to a global dysfunction of the upper midbrain. Third ventriculostomy contributes to equalization of cerebrospinal fluid pressure across the tentorium by restoring free communication between the infratentorial and supratentorial compartments, resulting in resolution of the patient's clinical symptoms.

Subtentorial diverticulum of the third ventricle associated with a mural cavernous angioma in a child

The authors describe a case of a large subtentorial supracollicular diverticulum of the third ventricle associated with a cavernous angioma in its wall in a 6-year-old girl who presented with developmental delay and obstructive hydrocephalus. This is the first case in which such association has been diagnosed and successfully treated. The literature is reviewed, and the possible relationship between these two rare lesions is discussed.

Diverticulum of the lateral ventricle causing cerebellar ataxia. Case report

A case of ventricular diverticulum causing cerebellar ataxia is presented. Computerized tomography clearly demonstrated the aperture of the diverticulum in the medial wall of the trigone and its extension into the posterior fossa. The diverticulum regressed and the cerebellar ataxia disappeared after placement of a ventriculoperitoneal shunt.

Spontaneous lateral ventriculocisternostomy documented by metrizamide CT ventriculography. Case report

In a patient with partially shunted obstructive hydrocephalus from a third ventricular astrocytoma, metrizamide ventriculography combined with computerized tomography demonstrated spontaneous ventriculocisternostomy with passage of contrast material from the atrium into the choroid fissure and posterior subarachnoid space.